In the United States today, transfusion of incompatible blood is the most common cause of serious morbidity and mortality related to transfusion. Transfusion to unintended recipients has been reported to occur at a rate as high as 1 in 400 units and each of these events has the potential for causing one of the approximately two dozen fatal transfusion reactions reported annually.
Errors associated with administration of incompatible blood in fatal transfusion reactions include misidentification of patient samples, errors within the laboratory and misidentification of recipients at the time of transfusion.
Current manual mechanisms for patient identification at the time of blood product transfusion require a healthcare provider to assess and compare the patient identification information of the actual patient and the blood product dispensed for transfusion purposes. Manual mechanisms have inherent flaws, such as failure of personnel to follow established policies and procedures which may allow the personnel to bypass the manual identification checks. Other flaws include failure of personnel to accurately compare the intended recipient to the actual recipient and failure of personnel to accurately compare the intended blood product to the actual blood product to be transfused.
Traditionally, patient identification has relied on manual comparison of one or more identifiers such as name, medical record number or financial number on a transfusion request form with information on a patient wrist band. In addition, many transfusion services have utilized secondary labeling systems (such as Hollister, Typenex, Secureline) to identify patients from whom samples have been drawn for compatibility testing and for matching products to patients at the time of blood administration.
Current automated systems for patient identification at the time of blood product transfusion are flawed in a number of respects. For instance, these systems do not provide real-time access to the direct blood product inventory information from the blood bank department nor do they provide real-time access to blood product testing results from the blood bank department, including compatibility testing results.
Current manual mechanisms for blood transfusion patient assessment and vital sign documentation also have a number of inherent flaws, such as failure to document all appropriate observations and activities, and inaccurate entry of data. Furthermore, manual mechanisms for blood transfusion patient assessment and vital sign documentation are time-consuming and costly.
Current automated systems for blood transfusion patient assessment and vital sign documentation also have a number of flaws. These systems cannot capture data related to the blood product transfusion, patient vital signs and assessment. This is due to the disintegration of the processes for blood product testing, release for transfusion and inventory (and product) documentation done by the blood bank department, and the processes typically performed by the nursing department for the actual transfusion documentation, including patient assessment, vital signs processing, and transfusion activities.
Accordingly, it would be beneficial if there was an automated system and method to eliminate transfusion of blood to unintended recipients. It would be beneficial if the blood product identity is maintained throughout processing in the laboratory and that the compatibility testing results for the blood product recipient be confirmed before blood products are infused. It would further be beneficial to capture and document patient vital signs during blood transfusion. It would also be beneficial to be able to automatically update the blood bank database when a blood product has been administered. Finally, it would be beneficial to integrate the processes performed by the blood bank department and the clinicians at the point of care.